tabulating

I’m nearly done with a third of the year spent in cardiothoracic surgery, and I’m counting down the days till I get back to general surgery. People keep asking, and I’m completely unable to explain why; but somehow, the strange fascination that drew me into surgery in the first place makes me most interested in general surgery. I’m looking forward to getting called to the ER to see people with appendicitis and cholecystitis and diverticulitis and abscesses. That’s weird, isn’t it? The CT guys keep telling me their stuff is cleaner – nothing too dirty or smelly in the chest – but somehow it doesn’t get my attention. Maybe because I didn’t ever spend much time with this in medical school, so it never seemed like a part of the real surgical world to me.

Nevertheless, despite having been anxious to be done with the rotation for the last two months, I’ve learned a lot.

– I’ve come to see the heart as a real object, with definite anatomy, and implications of that anatomy for patients’ health. Before, coronary artery disease was a nebulous kind of entity to me, and whether or not a heart attack occurred seemed just as rational as lightning striking. Now, I can read a cath film with some degree of accuracy, and the fellows finally succeeded in pounding into my head the difference between the acute marginal and obtuse marginal branches, between the diagonals and the septals. They’re as solid and real now as the superior and inferior mesenteric arteries: if you block any one of them, the tissue downstream will die.

Similarly, ejection fraction on an echo makes more sense, and the different valves that can be stenotic or regurgitant, and the different types of heart failure that will result.

– I’ve looked at a lot more chest x-rays and chest CTs, and I no longer skim through the lung windows of a chest CT as though they were a gray blur. I finally grasped what ground-glass opacities look like, and bullous emphysema, and some of the distinction between atelectasis and pneumonia.

– I am really good at arterial lines. After weeks of doing a couple every day on cardiac patients with poor peripheral circulation and/or no pressure and/or no pulsatile flow, the radial artery on a patient who’s only hypotensive seems to leap out. Radial lines used to be my least favorite line, and now they’re fun.

– The critical care attendings and the cardiac attendings, in between constantly disagreeing with each other about what pressor is good for what problem, at least taught me the actions of all the different pressors (not just the three most common), and a philosophy of choosing them rationally rather than at random. (I’m just ashamed it took me till third year to get this.)

– As the senior residents promised me all last year when I got too excited about what they considered to be a minor amount of blood, having seen blood pouring out of the heart when it’s being cannulated, having seen an ascending aortic dissection visibly expanding while we were struggling to get the axillary cannula in, having seen four liters of blood cleaned out of an open chest, having seen chest tubes drain one liter in two hours – I have developed the most shocking disregard for an artery or two shooting at the ceiling, or a central line site oozing continuously, or a vascular surgery wound soaking through a couple packs of kerlex. On the other hand, I have a new respect for the power of plasma and platelet transfusions, active rewarming, calcium infusion, and patience, to correct severe coagulopathies, without the need to operate on bleeding that you couldn’t really improve surgically.

– This skill will probably rarely be of use again, but I am a chest-tube-pulling machine. I can get an armful of supplies, and have ten chest tubes (ok, two per patient) out in half an hour, with no assistance, and no air leaks. Only valuable when you have an ICU full of post-op day 1 heart patients, or an entire list of post-op day 1 VATS patients, but it’s fun to surprise the patients with how easily it goes (usually). Trauma has a few chest tubes, but not this quantity, and by the next time I’m on trauma, I’ll be senior enough to tell someone else to pull the chest tubes. Maybe.

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